RO SOP

Question 1

What are the 3 types of specimens received?

Answer 1

Routine
Urgent
Referrals

Question 2

How are routine specimens received?

Answer 2

1. Collected and delivered to the receiving window
2. Request slips clocked with the current date and time
3. Specimen type and number of tubes recorded
4. Record initials on the request form
5. Return specimen to the biohazard bag
6. Maximum 10 biohazard bags in a lean bin

Question 3

Is batching of specimens allowed?

Answer 3

No

Question 4

How do you record additional specimen types (urine, csf) on the form?

Answer 4

“Other” and specifically stipulate

Question 5

How are urgent specimens received differently to routine specimens?

Answer 5

Priority handling
1. Open specimens 1 at a time and check for request, completeness and correct specimen type and collection
2. Place in the urgent lean bin

Question 6

Which samples should always be treated as urgent?

Answer 6

CSF
Bone marrow
Paediatrics
Transplant
NMCH
Delivered by the clinician
(FBC and UKE, according to supervisor)

Question 7

How is referral work received?

Answer 7

1. Ensure number of boxes delivered corresponds to the number of boxes on waybill before signing
2. Separate empty boxes from newly received boxes
3. Each specimen batch requires a packing slip - check specimens against the packing slip
4. Clock and initial the packing slip
5. Note sample condition on packing slip

Question 8

What do you do if the number of specimens does not correspond with the packing slip?

Answer 8

Alert supervisor or queries bench immediately

Question 9

Discuss the receiving of histology specimens

Answer 9

1. Record in the histology book
2. Place in blue bin for collection by histology staff
3. Collection on a daily basis minimum 3x per day

Question 10

Discuss the receiving of infection control specimens

Answer 10

1. Record in infection control book
2. Placed in infection control bin
3. Delivery by messengers hourly to the infection control lab

Question 11

Discuss the receiving of cytogenetic specimens

Answer 11

1. Record in the cytogenetics laboratory book
2. Placed in cytogenetics lab bin
3. Delivery by messengers hourly to the cytogenetics lab
4. Messengers then return the request forms in files the should be registered daily day and night
5. The clerk registering must ensure all completed forms are placed back in the file and in the completed rack
6. Ensure cytogenetics file number is captured in the reference field and 3 copies of the barcode attached to the request form

Question 12

Which details must be recorded in all the laboratory books (histology, infection control, cytogenetics)?

Answer 12

Patient name and surname
Hospital number
Date
Signature of clerk

Question 13

What do you do for cytogenetic forms which have queries?

Answer 13

Place in queries rack or take to supervisor immediately

Question 14

If a specimen is received from another NHLS lab, do you register a new HN number?

Answer 14

No!

Question 15

Discuss the process of capturing

Answer 15

1. 1 line bin at a time
2. 1 biohazard bag at a time
3. Confirm specimen matches form barcode
4. Confirm specimens all present and not compromised
5. Confirm demographics on form and capture under ‘patient entry’
6. Billing information
7. Capture correct tests
8. Print and place the barcodes on the form and specimens
9. Place samples on the conveyor belt

Question 16

Which information must be captured for private work?

Answer 16

Patient member number
Address
Contact details

Question 17

How do you split samples?

Answer 17

Place a split sticker on the primary tube and a barcode on a 5ml clear tube

Question 18

Which test is done first:
VL
CD4
FBC

Answer 18

FBC -> CD4 -> VL

Question 19

Discuss receiving of referrals

Answer 19

1. Ensure test is actually done at CMJAH
2. Receive samples individually
3. Ensure barcode sticker in correct position

Question 20

Which referral samples can be received using the packing slip?

Answer 20

Viral load

Question 21

Can receiving and scanning out of referral samples be done by the same person?

Answer 21

No

Question 22

What is the bench that follows capturing?

Answer 22

Scanning bench

Question 23

Discuss scanning bench

Answer 23

Sort specimens into disciplines and put onto specific worksheets that are printed and accompany the specimens to the relevant lab

Question 24

How long are rejected samples stored?

Answer 24

In the fridge for 7 days

Question 25

Which wards need to be contacted prior to rejecting specimens?

Answer 25

ICU
Paediatrics

Question 26

What are transcription checks?

Answer 26

Error checks done on randomly selected request forms daily (morning, afternoon and night)

Question 27

Which information needs to be checked in the transcription check?

Answer 27

Demographics
Billing information
Mandatory fields
Tests requested
Clock stamp
Signature
Form available on ECM

Question 28

What are the RO quality control indicators?

Answer 28

1. Transcription checks
2. Cancelled test report
3. Not priced report

Question 29

What is the cancelled test report?

Answer 29

Done monthly to indicate number of rejected tests and reasons, in order to identify trends and correct

Question 30

What is the not priced report?

Answer 30

Done weekly to identify incorrectly captured requests which affect billing

Question 31

How long are scanned ECM forms available on TrakCare?

Answer 31

5 years

Question 32

How long are hardcopies of request forms stored?

Answer 32

On site 3 months
Off site (Metrofile) 5 years

Question 33

Discuss bench disinfection

Answer 33

Start and end of each day
Record on log sheet
Log sheets filed and stored

Question 34

Into which bin are paper towels used to swab benches discarded in?

Answer 34

Biohazard NOT black

Question 35

Which RO instruments require servicing annually?

Answer 35

Clock machines
Barcode printers